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Physical therapy for musculo-skeletal neck and shoulder pain should include correction of both upper and lower body posture.
Physical Therapy should be more than a spa experience and more than a patient robotically doing a long list of exercises without knowing the specific purpose for each and how to monitor his or her own progress. In order to assign fewer but more precisely targeted exercises, the testing and initial evaluation are of utmost importance. After introducing the exercise, the therapist must follow through by carefully monitoring the patient for correct form, effort and time taken during the assigned exercises.
One other roadblock to recovery from an acute injury such as a whiplash injury is the patient’s coping style. Treat the whole patient, not just the symptoms, and teach patients what they need to know so the problem is less likely to return. My first PT in particular, the spine specialist at a large PT practice, and the only one (of four) that I brought my MRIs too, was dismissive when I told her that I still had neck pain doing the exercises. My reply to a support group post from a woman, who was prescribed muscle relaxers and physical therapy. The right kind of therapy requires an initial evaluation for postural alignment, and then  a program of strengthening elongated, weak postural muscles, such as the back muscles, and stretching the tight muscles, which are often the chest muscles, so that you can more easily maintain correct alignment of the upper body. After that, any other kind of hands-on treatment a PT wants to give: heat, ice, electrical stim, mobilization, or traction may help with relaxing tight neck muscles but only in the short term unless the posture alignment issue is also addressed.
Correcting posture of the lower body is a major factor in improving alignment of the upper body. When the back is excessively rounded forward, discs are unevenly stressed, and over time their outer layer or annulus prematurely develops tiny cracks that cause loss of moisture and disc height, which causes spinal instability, increased pressure on facet joints, bone spur formation and stenosis. There is already a natural imbalance of weight due to the rib cage chest area extending out front of the thoracic spine, (which has a natural kephotic (posterior) curve to counterbalance the rib cage (see balanced posture at left) and this weight imbalance causes a constant forward bending pressure on the spine that must  be resisted for the body to stay upright. With excessive rounding of the upper back, the body must realign itself to keep from falling forward. The Thinker by Auguste Rodin, one of the most recognizable sculptures in Western Culture, is an example of really bad posture. Myley Cyrus, like many teenage girls, tends to have curved forward shoulders, rounded back, and depressed chest. This is approximately what my posture looked like before I realized that slouching had caused my chronic neck pain.
A panoramic rear view mirror* became a necessity when my neck muscles were so spasmed I could barely turn my head. To help with seeing cars  in the blind spot, I use a little stick-on convex mirror in the corner of the driver’s side-view mirror.
As much as possible, the brain converts repeated actions into automatic routines or habits in a process called chunking. Trying to change a habit sequence once it’s triggered is difficult because the conscious brain is not actively involved.
For an interesting article on habits see the New York Times Article, How Companies Learn Your Secrets (they want to know when a life changing event, such as impending marriage or childbirth will occur, in order to get a headstart sending out advertising. However, there is a matter of backsliding into poor posture, and I do find myself slouching, but only when working long hours at the computer, not when standing, walking or other more physical activities. Ultimately, maintaining good posture is a continuous challenge, but it is a challenge that can be won, if one becomes aware that it feels so much better (the reward) than slumped posture.
My son, a personal trainer, mentioned that one of his clients was complaining of neck pain. When using a cell phone for text messaging, anchor your upper arms close to your body and bend your elbows to raise the phone closer to your face. A handheld tablet with keyboard seems like it would be very awkward to type with (needs thumb-typing or one-handed typing). Typing on a laptop rather than a tablet should be easier on the neck, as long as it is on a surface like a table top, which it seems most people do. For an informative video on improving sitting posture to avoid neck and shoulder pain due to prolonged desk work, computer and mobile device use; see Sitting At Your Computer on Dr. I myself took Glucosamine and Chondroitin for several months without positive effect, but then Celebrex at that time didn’t help either. As a teenager I dabbled in it, but either injured myself as when I tried a yoga headstand and strained my neck, or began wondering what all that extreme twisting and bending was doing to my joints and ligaments.
EF: You now have a spinal fusion and screws in your lower lumbar spine to stabilize herniated discs and spondylolisthesis. With knee flexed, Sartorius muscle carries out flexion, abduction and external rotation at the hip joint. Serratus Posterior fibers when contract bilaterally lead to extension of the trunk, while acting unilaterally they pull the outer edges of the ribs toward the vertebrae bending the trunk to one side. Other extensors of the trunk include the small deep lying Rotatores and Multifidus muscles. Without using the bolster, the knees are brought closer to the floor while keeping the arms fixed on the floor. When it comes to squatting and deadlifting strength, the thoracic extensors play an even greater role in stabilizing the spine than the abdominals. This shows that performing isolation movements for the spine can directly improve deadlifting performance. Needless to say, both the lumbar and thoracic spine need to be incredibly strong to hold the pelvis in place and prevent the spine from buckling during heavy squat, deadlift, and good morning variations. While the lower back does flex slightly when performing thoracic extension exercises, trying to maintain a lumbar arch ensures that it doesn’t round excessively and that the vast majority of motion comes from the upper back.
A variety of barbell, safety squat bar, chain, kettlebell, band, and dumbbell exercises can all be used to develop upper back strength. Here’s a video that shows how to do all of these movements, with descriptions to follow.
The trick with seated good mornings for upper back building is to make sure you feel it in your upper back. You can hyperextend the t-spine with these and obtain good resistance through the entire range of motion. Chains are my favorite way to load this movement, but you can pretty much use anything – bands, a barbell, a safety squat bar, a cambered bar, or a dumbbell. What’s best about this exercise is that you can tinker around with torso hinging placement to target different areas of the t-spine.
The seated kettlebell deadlift is highly effective for thoracic building, but you need a heavy kettlebell. The upper back extension performed with a dumbbell is another simple way to load the t-spine, assuming you have access to a GHD.
Powerlifting legend Fred Hatfield used to perform this exercise with 225 pounds for sets of 10 reps using a special contraption that allowed him to hold a loaded barbell up closer to his chest so he could achieve full ROM. Squats and deadlifts can build a world class back, but isolating joint actions can thicken your thoracic region and help you blast through plateaus.


I recommend hammering the erectors for three weeks by incorporating some of these movements into your regular training.
Stretching GuideWe’re pleased to introduce the Psoas Stretching Guide to help integrate stretching into your day. If chronic musculo-skeletal pain is involved, it may be complicated by poor posture alignment  stemming  from long-standing habit,  a secondary consequence of an acute injury, or the weakening effects of chronic illness. This combination didn’t help after 2 weeks, so her doctor stopped both and prescribed Celebrex instead.
Correct alignment of the upper body yields correct alignment of the head and neck, which will relax tight posterior neck muscles and strengthen weak anterior neck muscles.
But why does it seem to take so much more energy to keep the spine straight than to slouch, especially with fatigue or illness.
The pelvis rotates backwards, trying to pull the upper body upright, and pulls both the lumbar and mid thoracic spine flat. The upper torso shifts backwards in a long, rounded curve that is also counterbalanced by the pelvis shifting forwards. The excessively hunched upper back is counterbalanced by the abdomen, which pooches out in front because of an excessive inward lordotic curve of the lower back. When the back is as straight as possible, given the natural curves,  body weight is close to being balanced around the spine.
Add a chronic illness, and it seems like there’s little energy left to stand tall with good posture. In Duets, a marvelous  movie combining multiple story lines with love and karaoke,  Paltrow exaggerates her poor posture even more to portray a gawky, young innocent, who melts the heart of her long absent karaoke-hustler father, played by Huey Louis. Unfortunately, none of the many doctors or the four physical therapists  I went to for help ever mentioned my poor posture as a possible cause of neck pain. This is particularly true of the mat exercises, which include crunches (modified sit-ups) for strengthening abdominals,  and also the bending-forward, reaching-for-the-toes exercises for stretching hip extensors (hamstrings). One approach in particular seems to help; a study on exercise habits showed that when participants were educated about habit formation and then asked to identify cues and rewards that might increase participation in exercise routines, they exercised twice as much as those who only received lessons on the importance of exercise.
My experience has been that the feeling of slumped posture can become a cue, and when I become aware of it, I tighten and straighten my mid-back, which lifts my chest and gives me a feeling of release from chest constriction (a reward) and I take a deep breath. The good thing is though, that I’m more aware of slumped posture, and I put more effort into correcting it.
But still the monitor cannot often be raised to comfortable eye level so see people bending their necks down all the time. There are people I know who claim they have been helped, especially by formulations with MSM, but it’s no miracle cure.
I watched my dad, a student and teacher of Hatha yoga, who did the positions much better than I could. However, a recent article in the New York Times, How Yoga Can Wreck Your Body, discusses the small but growing numbers of serious injuries to the lower back, shoulder, knee and neck. These muscles are susceptible to injury because they are not trained by normal exercise routines. They turn the spine towards opposite whereas their bilateral action leads to trunk extension. And while many lifters perform accessory movements for the quadriceps, hamstrings, gluteals, and abs, most lifters don’t do any accessory work for the erector spinae. According to Hamlyn et al., the lumbar erectors fire harder during squats than deadlifts, but the thoracic erectors fire harder during deadlifts than squats.
When you perform thoracic extension exercises, it’s very important to do them properly. Moreover, the lower lumbar spine and pelvis will remain stabilized with any lumbar motion occurring in the upper lumbar spine. Do these in a power rack and make sure you set the j-cups and safety pins at the appropriate heights. If you keep a big arch you can make it more of a hamstring movement, but you don’t want this.
Set up in a glute-ham developer (GHD), round the torso over the pad, and make sure your knees are bent so the hamstrings don’t contribute to the movement. Lower torso placement on the pad targets the lower thoracic region, mid placement targets the mid thoracic region, and upper placement targets the upper region.
The video shows me using a 48-kilogram (106-pound) kettlebell, but it’s still a bit light. Load up a barbell with 130-150% of your 1RM front squat, un-rack, keep the chest tall, squeeze the abs and glutes, and hold for time. Simply stand on the elastic band (or on multiple bands if you don’t have strong ones), wrap it around your neck, and flex and extend the upper back. Try to hold the dumbbell up near chest level, because if you let it sink to navel level it reduces the torque loading on the spine.
He felt that this exercise was very helpful in allowing him to achieve a 1,000-pound squat way back in the day.
A randomized trial to consider the effect of Romanian deadlift exercise on the development of lumbar extension strength. Trunk muscle activation during dynamic weight-training exercises and isometric instability activities.
Our therapists will use this guide to customize a stretching plan to help the benefits of massage last longer and to encourage overall good health. But later when I did the exercise using a mirror set-up so I could see my back and the muscles around the shoulder blades during the exercise, and could concentrate on the muscles to make them contract harder, that made all the difference. When I had physical therapy for knee pain (PT course # 7), the physical therapist showed me that my knee caps had drifted off center. Sometimes I imagine running into her at the grocery store and saying “Look at me now, 8 (or so) years later and I can do whatever I want, with no neck pain and no surgery.
If energy efficient means using the least amount of energy to perform work then at first glance, slumping with rounded back does seem to take less energy because the back extensors, a large group of back muscles, slack off from straightening the back and let the weight of the upper body hang passively off spinal ligaments and joints.
But since the upper back and head are still held forward of the torso, and there’s no counter-balancing curving of weight to the back, the entire body leans a little forward, not so much that one would fall over (unless trying balance exercises), but enough to have difficulty flattening the entire back and head against a wall without extending (bending slightly backwards) the back. Against a wall, the upper back and butt may touch, but there’d be lots of space between wall and lower back.
The vertical black line (the center of gravity) in the posture illustrations, represents equivalence of weight in front of and behind the line.
But it is so worth the effort because the strength and balance of postural muscles is preserved and the chances of postural neck and back pain are greatly reduced.
His lower back is rounded, which puts excessive, one sided, pressure on the intervertebral discs of the lumbar spine. But crunches can worsen sway back posture, and touching the toes, though supposed to be done with straight back, end up being a back flexion stretch as most of the participants round their backs in the effort to reach their toes.
I intend to stay with the class especially for the step aerobics, which gets the heart pumping but not excessively.


Tai Chi is done slowly, mindfully, with arms and legs coordinated and both moving throughout the movements. Then I do a rep of the Fix the Shoulder Blades Exercise, during which I often remember how much better my profile looks (even when I’m not anywhere near a mirror) and how good my neck feels now versus how miserable it used to be (more rewards). It turned out that excessive tablet use coupled with poor posture was the source of her pain. Glenn Black, a well known New York instructor states that injuries occur because students have underlying weaknesses that need to be addressed first. Bilaterally they provide a supportive embrace to the trunk along with the deep lying Transverse Abdominals muscle.
This stretch not only rotates the hip joints inwards but also extends the usually stiff pelvic (sacro-iliac) joints. Just bring your parking stub to the Psoas front desk, and we’ll validate it for up to 2 hours. Combining visualization and actual performance might speed improvement, and in my experience the two together make all the difference. Nothing in my experience of 6 courses of physical therapy for neck and shoulder came close to the way I worked those shoulder blades.
He didn’t use technical terms but explained to me why I needed to strengthen my inner thigh muscles and stretch the outer thigh muscles to recenter my knee caps. What use are your fancy spine mobilization techniques and all the weekend continuing education classes, when in the end they weren’t effective at all?
When weight is balanced, posterior muscles like back neck muscles and lower back muscles, as well as hip extensors (hamstrings) (depending on the type of faulty posture) are not over-worked. Meanwhile the strengthening of back extensors, the muscles that pull our backs erect,  is ignored.
There is no pressure to do all the exercises and I can opt out of the exercises that are counter to my posture type (flat back). The cue and the reward become associated so that when the cue is present, a craving to perform the sequence emerges. For example, I put a pedometer (a Fitbit) in my pocket after dressing in the morning (the cue) and take one walk then. Finding and appreciating those rewards required that I become more aware of how my body looks (especially from different points of view), and also more sensitive to how my body feels, not just pain, but muscle tension, joint position, limitations imposed by poor posture, awareness of shoulder blade anchoring, spine position, posture during movement etc., or everything that comes under the classification of kinesthetic senses. Perhaps because computer work takes a great deal of mental energy, and the mind and body tires quickly. Another study specifically studied 250 adults with chronic low-back pain and degenerative arthritis for a year. He would remain in a headstand propped against a wall for quite some time—his face turning bright red. Also mentioned is Yoga Instructor, Carol Krucoff, who tore a hamstring muscle while being filmed doing Kitchen Yoga for a national TV show.
Their unilateral action leads to flexion and rotation of the trunk while contracting bilaterally they flex the whole trunk.
This is a great exercise to aid in sports and activities involving turning and twisting of trunk such as swimming, jumping, cycling, running or walking. And if the ten to fourteen pound head juts out in front of the body because the top of the thoracic spine curves forward, and the upper chest and back, shoulder and arms also curve forward, it’s more difficult. But also front postural muscles like neck flexors, abdominals and hip flexors are not under-worked and weak.
In my defense, I had a debilitating stomach illness, was in a lot of pain and my neck felt so weak I could barely make it to PT sessions. However, from what I see so far, Tai Chi by itself does not improve posture. Over half the participants have a more kephotic upper back than is healthy. Sometimes I wonder why I didn’t naturally have those sensitivities when I was younger. And being tired means less energy for the back extensors, which are the critical muscles keeping our backs erect against gravity. Later I wondered if that had something to do with the Alzheimer’s that overtook him in his late 60s. See Insight from injury: If the practice of hatha yoga was meant to heal, why are so many yogis getting hurt? The fact is that by itself the normal spine cannot be both flexible to allow us to bend down to tie our shoelaces and inflexible enough to completely support our bodies. The more bending forward exercises there are, the more that body and posture will tend to bend forward. My son bought a case that tilts the Ipad up so he doesn’t need to tilt his head down as much. A more recent study involving 662 GAIT patients looked at glucosamine and chrondroitin sulfate, either separately or combined, and celecoxib (Celebrex) as well as a placebo. Instructor Glenn Black in another interview, Yogi Glenn Black Responds to New York Times Article on Yoga, lists pinched nerves in the neck, low back tightness, injuries to hips, knees and shoulder problems and also which yoga poses to avoid. Or not so obvious: washing up before bedtime (cue) triggers toothbrushing, and afterwards the feeling of a clean mouth serves as the reward.
He also says a case is available that comes with a separate keyboard and also elevates the Ipad.
At least the monitor can be adjusted to a comfortable height, which for me is just below eye level, so I can see it in the reading part of my eyeglass lenses without tilting my head up.
For ideal posture the extensors and flexors act in concert to stiffen the spine in as close to a vertical position as the natural curves allow. Some cues and rewards are so slight that one may hardly be aware of them, but our neural systems certainly are.
The thoracic spine, in particular, supports the ribcage and attached muscles and organs, which are a major part of the body’s mass. And perhaps also, poor posture itself, and any pain from poor posture, deadens sensitivity to body state. No wonder the thoracic spine, which naturally has a rounded, kephotic curve, tends to curve even more forward under that weight if the back extensors aren’t kept strong. Is it any wonder that a person’s posture seems to be a relatively unchanging part of his or her physical appearance, except to slowly get worse with age? And once some improvement has been experienced, the body becomes more sensitive to what a healthy postural state feels like, and strives to maintain that state.



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